15 November 2022: Melville - B

Core participant questions:

On the involvement of patients in training of doctors; he said that was a question for the medical schools, but there is a requirement on schools for “broad stakeholder involvement”, and that would include patients. He stated that the “patient voice” was something the GMC were keen to hear so that the guidance was relative to them, too.

On who is involved in drawing up the guidance the GMC uses; he said out of the 1,400 employees of the GMC less than 20 are doctors. They have a Council with is made up of 50% doctors and 50% non-doctors or lay people; six and six of each. Guidance comes through those from a policy perspective and involved consultation. The process is to start with the evidence and turn that into a framework. That then goes out to consultation and eventually the wording is finalised.

On the consultation including “hard to reach groups”; he said he couldn’t say they do reach everybody, but in the case of the Good Medical Practice document they used an external agency to identify and engage with people who might have a hearing difficulty, a rare disease, who come from an area of multiple deprivations.

On the proposal to use the Contaminated Blood Scandal as an example of when openness and transparency are not part of healthcare culture; he said “of course”, although it would not be the only example used (… thereby admitting there are other examples). It would be up to individual educators to select how case studies are used.

On how the GMC updates its guidance after a report or court decision (with the example of the Montgomery case on consent being mentioned); he said there is a team that looks at all Inquiries and judgements and any impacts these decisions or recommendations might have on the guidance or publications of the GMC. For Montgomery the guidance was already compliant, but otherwise he could not say how long it takes to change since it is different each time. If required, a change might have to be made right away.

On the use of the “you must” and “you should” and the possibility of training on language use being required; he said the language is developing, and they are now moving to use the phrase “You will” to give a sense of ownership.

On the bias related to women and if womens’ voices were involved, for example, on discussions about pain; he said he could not say, but maybe the College of Obstetrics and Gynaecology may be netter placed to answer.

On the apparently busy lives of doctors which makes it hard to keep up with guidance changes from the GMC and other sources; he said the periodicity is not frequent. As a clinician he did not see it as impossible to keep up. Changes are published six months before implementation anyway. Counsel followed-up with an example of a change related to Duty of Candour produced jointly with the National Midwifery and Nursing Council, asking if the witness would expect every doctor to read it. He said he would hope so but noting that for the period of particular interest to the Inquiry there were no electronic communications. Nowadays information can be streamed to those it applies to without flooding everyone with everything. They do try to monitor access by the “click-through” rates achieved. The outreach team would also engage with key people and organisations. The GMC has 300,000 registrants. The mostly work at medical school level or in trusts. There are 40 medical schools and 200 trusts in England alone.

On the GMC producing teaching guidance to employers and medical schools on new guidance; he said they are not a curriculum provider, but they do produce case study examples on certain topics related to ethics and standards. (So, for the earlier question about using the Contaminated Blood Scandal being up to the schools, he could have said that the GMC would be happy to work with the Inquiry or others to produce a case study, but he did not offer to do that for some reason.) The witness admitted that the take up rate on their website was not great and they are trying to work out how better to get messages across. (Is this an admission that the GMC simply doesn’t know how much of their stuff gets read, but at least one big indicator is that the answer might be, “Not a lot”.)

On any contact with the National Guardian Office; he said if that was referring to the National Guardian of Safe Working then there was some contact, as there also contact with the Patient Safety Commissioner, along with other regulators which allows for information sharing.

On there being limitations related to passing on information or concerns about someone like a college dean; he said they would need to check for confidentiality issues with their in-house legal team, but there would be ways.

On the witnesses’ views of how placing the Duty of Candour on to a legal footing has made it more effective; he said Duty of Candour was not a legal duty on doctors, it was a professional duty. Counsel clarified that it was a statutory duty on an organisation, but not an individual. The witness did not think it would help to make Duty of Candour a legal duty on individuals, despite how some people might think otherwise. He felt it would reduce openness and disclosure. It is better done in a learning way than a sanctioned way. Things have come a long way, he said, “a step-change” in fact towards a greater sense of openness. He recognised that the move to investigate “what happened” and not so much “who did it” was controversial to some people since it stressed organisational learning and not so much individual accountability.

The Chair asked about Duty of Candour on organisations. He said that an organisation can only act through individuals. It has to be the individual who sees there is a problem, but how does the organisation know of a problem if the individual doesn’t say anything. The witness spoke about the individual need to be open and honest to allow the organisation to then respond. He seemed to be running into a logical dead end, so the Chair stepped in to assure the witness he thought he saw where his thinking was going with his point. This writer was not so sure.

The Chair then asked about the change from “You must”, to “I will” and why that could not be “I must”. The witness gave an explanation which separated the “I will” into a set of assertions at the beginning. The “You must/should” remains later in the document.

The Chair mentioned the very large numbers of core participants who had described how they were told about a viral infection in a brief, off-hand way, maybe brutal way. It may even have happened in a hospital corridor or waiting area. The Chair was interested to understand how the GMC overcomes what might be a reflection of personality style in breaking news in some way? The witness spoke about the importance of “how” and not “what” bad news was communicated. There needed to be empathy, to see the situation from the patient’s perspective. They are working to promote compassionate cultures and compassionate leadership. He recognised the challenges in changing cultures, both the individual and the leadership aspects. He noted the lack of reference to “paternalism” in the evidence he had given. Paternalism was recognised as a problem in the past within the world of healthcare, and may still be experienced, but hopefully to a lesser extent.

The Chair noted the descriptions the witness was using of “looking at” and “getting there” suggesting that progress is being made, but it has not been arrived at yet. The witness accepted the observation. The work is ongoing, and it is not easy to recognise how far along the journey they are.

The Chair concluded with a catch-all question about anything that the witness recommends as needing to be done, The witness spoke about identifying problems, particularly if the organisation involved did know it was seen in the way it was seen to be. It would be a partnership approach. He mentioned how he had learned the powerfulness of the patient voice.

The witness simply repeated how he recognised the difficult journey for patients, their friends, and relatives. If anything comes out of the Inquiry which will require action and learning, they “absolutely want to do that”.

The Chair thanked the witness and said his evidence had been most useful.